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01 <br /> SAN JOAQL 70UNTYNV AL HEALT EPARTMENT <br /> SE UEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Motor Vehicle Fueling Station 2&t � 59Z�D56 / D(I <br /> OWNER/OPERATOR <br /> BP West CoaS r0Its LLC CHECK if BILLING ADDRESS <br /> FACILITY NAME ARCO AM/PM <br /> SITE ADDRESS 1711 East to Boulevard Manteca 95336 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from it ress) 4 Center ointe Drive <br /> Street Number I Aft Street Name <br /> CITY La Palma TATE CA ZIP 90623-1066 <br /> PHONE#1 EXT. N# LAND USE APPLICATION# <br /> (949) 364-4369 X� 208-310-12 <br /> PHONE#2 EXT• BOS DISTRICT_ LOCATI CODE <br /> ( ) <br /> CONTRACTOR / SE4V QUESTO <br /> REQUESTOR Ruth <br /> ECK If BILLING ADDRESS❑ <br /> BUSINESS NAME BP U. nvenience Retail PHONE# EXT. <br /> 50 5-2982 <br /> HOME or MAILING ADDRESS P.NJBox 6038 FAX# <br /> ( 8 30-0912 <br /> CITY Artesia STATE C ZIP 90702 <br /> BILLING ACKNOWL ENT: I, the undersigned pr rt y r business owner, operator or authorized agent of same, <br /> acknowledge that all site and7N project specific ENVIRONME L EALTH DEPARTMENT ho�harges associated with this project <br /> or activity will be billed to me or my business as identified o s <br /> I also certify that I have prepared this application and that the o o be performed will be ne n accordance with all SAN JOAQUIN <br /> COUNTY Ordinance o Standards,STATE and FEDERAL s <br /> ` f <br /> APPLICANT'S SIG A <br /> PROPERTY/BUSINE NER f ( ` <br /> OPERATOR/MANAGER OTHER AUTHORIZED N ❑ <br /> L—ffLcapp <br /> ANT is not the BILLING PARTY.pro o thorizadon to sign is required Title <br /> AUTHORIZATIO O RELEASE INFORMATION: applicable, I,the owner or operator of the property locattd at he <br /> above site avresiAreby authorize the release of any and all results, geotechnical data and/or environmental/site assess nt <br /> information to s N 10AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT� on as it is availabl a e same tim t is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -fZ & • D <br /> COM S: <br /> Ute <br /> _ 0 08 <br /> tx' � � ��✓ �H � ENV! G E HEALT <br /> PE IT CES <br /> ACCEPTED BY EM E#: Z DA . t <br /> ASSIGNED n ( f� C{ EMP 12(.Er7 C' <br /> Date Service Completed (if already completed): SERVICE CODE: -F/E: <br /> Fee Amount:, Amount Paid o Payment Date <br /> Payment Type ✓ Invoice# Check# g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />